Cognitive assessments for older adults: Which ones are used by

Canadian therapists and why

doi:10.2182/cjot.07.010 This paper was published in the CJOT Early Electronic Edition, Fall 2007.

Alison Douglas ■ Lili Liu ■ Sharon Warren ■ Tammy Hopper

Key words ■ Cognition ■ Assessment ■ Older adults

Mots clés ■ Fonctions cognitives ■ Évaluation ■ Personnes âgées

Abstract Background. Occupational therapists routinely evaluate cognition in older adults, yet little is known about which assessments they use and for what purposes. Purpose. To examine the standardised and non-standardised assessments used by occupational therapists to evaluate cognition. Method. A random sample of 1042 Canadian occupational therapists completed the questionnaire by e-mail, post, or Internet website (n=247, response rate: 24.5%). Results. Respondents reported using 75 standardised and non-standardised measures. The assessments were grouped according to theoretical approach: bottom-up (assessment of cognitive components), top-down (assessment of function) and combined (either of above, plus interview). Theoretical approaches were used similarly across regions, despite differences in reporting of particular assessments. Therapists used more bottom-up assessments that were standardised, identified deficits, and easy to administer. They used more top-down assessments that were non-standardised, predicted function, and fit with their theoretical approach. Conclusion. It is recommended that standardised top-down assessments be developed to support evidence-based occupational therapy.

ognition is one of the outcomes most frequently mea- therapy practice in the use of cognitive assessments with

C sured in health care (Miller & Weissart, 2003). The

majority (60%) of occupational therapists work with seniors aged 65 and over (Canadian Association of older adults. Cognition is defined as processes in the mind that pro- duce thought- and goal-directed action (Vining Radomski, Occupational Therapists [CAOT], 2004a) and therapists rou- 2002). Occupational therapists assess cognition with respect tinely assess cognition in older adults (Grieve, 2000; Strub & to occupational performance (CAOT, 1997), which is the abil- Black, 1993). Although the literature contains descriptions ity to function in the tasks, activities, and roles that define the and recommendations for cognitive assessment in occupa- person as an individual (Law, Baum, & Dunn, 2005). The tional therapy, little is known about current practice and the client's cognition is assessed as a component that affects therapists' reasons for choosing certain assessments. The pur- occupational performance in the areas of self-care, produc- pose of the study was to describe the current occupational tivity, and leisure (CAOT, 1997). Thus, the cognitive assess-

ment is part of the process of assessing the client's roles and approaches with other client groups. For example, a prefer-performance of occupations. ence for non-standardised over standardised tests was found The occupational therapy literature provides descrip- among occupational therapists whose clients had rheuma-tions of various assessment approaches including: 1) the toid arthritis (Blenkiron, 2005). In addition, therapistsbottom-up approach, 2) the top-down approach, and 3) the working with children with autism reported using non-combined approach. Using the bottom-up approach (Duchek standardised assessments more frequently than standardised& Abreu, 1997; Grieve, 2000; Vining Radomski, 2002), the ones (Watling, Deitz, Kanny, & McLaughlin, 1999). A recenttherapist focuses on cognitive capacities, such as memory or decline in the reporting of bottom-up, standardised assess-attention, and uses performance to infer potential function in ments in pediatrics has been hypothesized to be linked to andaily life. The top-down approach (Duchek & Abreu; Grieve; increase in the use of functional standardised assessmentsVining Radomski) refers to the therapist's observation of a and observation of functional skills compared to previousclient's performance of everyday tasks to ascertain cognitive surveys (Burtner, McMain, & Crowe, 2002).abilities. The combined approach (Vining Radomski) pro-vides information not obtainable from the previous Purposes and reasons forapproaches. Information may include data obtained from cognitive assessmentclient self-report and caregiver report on standardised ques- The three purposes for assessment have been described bytionnaires or from interviews. Kirshner and Guyatt (1985). These are to (1) identify deficits, either by screening or more detailed assessment, (2) predict Standardised and non-standardised function, such as safety or need for services, and (3) measure methods for assessment change, which includes obtaining baseline and measuringStandardised assessments are those ones which use a docu- outcomes.mented protocol, are scored, and are administered under uni- Therapists must select amongst a wide array of mea-form conditions (Mandich, Miller, & Law, 2002; Vining sures. A review of the occupational therapy journalsRadmoski, 2002; Wheatley, 2001; Wilkins, Law, & Letts, 2001). (CINAHL database) and textbooks (Asher, 1996; Duchek &They have the advantage of providing objective, quantifiable Abreu, 1997; Goslisz & Toglia, 2003; Grieve, 2000; Law et al.,data and a common terminology to communicate with other 2005; Vining Radomski, 2002) identified at least 26 cognitive,professionals on the health-care team (Wheatley, 2001). They standardised assessments that were recommended for cogni-also form a foundation for evidence-based practice in that tive assessment with older adults (Douglas & Liu, 2005).they can be used to compare clients to a normative group, and Choices of assessments are based on psychometric prop-scores cumulated across clients can be used to evaluate inter- erties and other factors, such as clinical utility and theoreticalvention (Mandich et al.). construction (Law et al., 2005). Several textbooks offered pri- Informal or non-standardised assessments do not follow marily descriptive information about cognitive assessmentsa standard protocol and include such measures as interviews in occupational therapy without providing a critique of theand observation (Pedretti & Early, 2001). For example, a clin- rigor of their psychometric properties, such as reliability andician may observe clients in the kitchen to determine their validity (Gélinas & Auer, 1996; Goslisz & Toglia, 2003; Viningability to organise and plan (Vining Radomski, 2002). Radomski, 2002). Furthermore, each textbook provided a Non-standardised assessments have the disadvantage of different list of assessments, and the criteria for inclusion ofbeing highly subjective. Results from these assessments are instruments were unclear. Textbooks dedicated to reviewinginfluenced by the therapist's opinion of what constitutes psychometric properties for occupational therapy outcomeimpaired performance, and by the therapist's ability to deter- measures did not include a comprehensive list of direct mea-mine the relationship between specific behaviours and cogni- sures of performance components, such as cognition (Asher,tive processes (Vining Radomski, 2002). However, 1996; Law et al.; Letts, Baum, & Perlmutter, 2003).non-standardised assessments also have advantages: they Few critical reviews were available that pertained to theprovide important functional information and may be used psychometric characteristics of cognitive assessments forto assess clients who cannot tolerate a full standardised test or older adults. Kirkpatrick and Jamieson (1993) examinedfor whom communication is difficult (Vining Radomski, standardised cognitive measures for use in a cardiac unit.Wheatley, 2001). They can also be individualised to a client's They reviewed 12 brief neuropsychological screening testsparticular goals and environment, which may change over and five tests from the rehabilitation literature. They foundthe course of therapy (Mandich et al., 2002). that the data they reviewed supported superior validity and The frequency of use of standardised and non-standard- reliability of the brief neuropsychological screening tools.ised assessments by occupational therapists working with Again, the inclusion criteria were not specified. Medical lit-older adults is unknown; however, some evidence exists to erature reviews of cognitive tests for dementia have focusedsupport increased frequency of use of non-standardised on brief screening instruments favoured by physicians

(Lorentz, Scanlan, & Borson, 2002), and excluded assess- that were found in the literature review. It was piloted by five ments described in the literature for occupational therapists. occupational therapists who gave feedback about clarity, Aside from psychometric properties, clinical utility and completion time, and face validity of the instrument theoretical construction are also considered by occupational (Portney & Watkins, 2000; Streiner & Norman, 1995). The therapists when choosing an assessment tool (Law et al., questionnaire contained three sections: Part A: Theoretical 2005). Clinical utility refers to the usefulness of the results, approaches to assessment: respondents indicated frequency of time required for training, ease of scoring, administration, use of each approach. Part B: Specific assessment instruments and interpretation, fit with clinical setting, and the purpose used: respondents listed up to five assessments they used of the assessment. Theoretical construction of the tool refers (either standardised or non-standardised), and rated fre- to the fit between the assessment tool and the clinician's the- quency, purpose, and reasons for their choice. The purposes oretical approach to occupational therapy. For example, listed were: (1) identify deficits (includes screening or more when assessing the performance of daily activities (top-down detailed assessment), (2) predict (safety, compensation or approach) a therapist may be more likely to favour assess- need for service in the community), and (3) measure change ments that allow direct observation of daily activities. (includes obtaining baseline, measures outcomes). The rea- sons for choice were listed for ranking by the participants, Study objectives and can be seen in Table 7. Part C: demographics: respondents The four objectives of the study were to describe (1) the fre- indicated their primary practice setting, geographic region, quency of theoretical approaches used and whether frequen- age category, and gender (Douglas, 2005). cies varied by geographic region; (2) which assessments the respondents were using (e.g., bottom-up or top-down, stan- Participant recruitment dardised or non-standardised); (3) the purposes for which The sample size calculation was based on an estimated the assessments were used (identification of deficits, predic- response rate of 35% and indicated that 364 respondents tion, and measurement of change); and (4) the importance of were needed. The expected response rate of 35% was based their reasons for choosing their assessments. on previous surveys of Canadian occupational therapists; however, survey response rates generally are much lower. For Method postal surveys, response rates have been noted to be between Design and development of survey tool 30 and 60% (Portney & Watkins, 2000), but as low as 5 to A combined or multimodal design (Schaefer & Dillman, 10% for some questionnaires (Edwards et al., 2003). For 1998) for the postal and Internet survey was chosen for this electronic surveys, response rates have been reported to vary study, because it is associated with increased speed, and between 19 and 43% (Yun & Trumbo, 2000). There is no reduced costs and respondent burden compared to telephone standard for an acceptable survey response rate (Cummings, interviews and postal-only surveys (Schaefer & Dillman). Savitz, & Konrad, 2001); however, lower response rates The combined design addresses potential sampling bias by increase the likelihood of response bias (Edwards et al.; ensuring that those individuals without access to the Internet Portney & Watkins). have equal ability to respond. Individuals were eligible for the study if they were occu- Although there is debate over whether response rates are pational therapists who had consented for their contact greater for postal, e-mail, or web-based surveys (Klein, 2002), information to be released, worked in Canada, and had direct e-mail and postal surveys have been shown to be equally effec- client contact with older adults. The OT Networker database tive (Schaefer & Dillman, 1998). In this study, e-mail requests from the CAOT (CAOT, 2004b) provided contact informa- were sent to all those with e-mail addresses, as the response tion for those that met the criteria. The sample was stratified rates were not expected to be significantly different between by province of residence according to the national distribu- e-mail and postal response rates, and e-mail notices are asso- tion of occupational therapists (CAOT, 2001). Ethics ciated with reduced cost. The e-mail requests directed the approval was obtained from the University of Alberta Health respondents to a web-based survey. Web-based surveys have Research Ethics Board. The study adhered to ethical princi- numerous access advantages over e-mail surveys, which ples of confidentiality, informed consent, voluntary partici- include reduced risk of file corruption and reduced deletion pation, and explanation of risks and benefits. The due to "spam" filtering and fear of viruses (Dillman & Bowker, questionnaires were mailed or e-mailed to 1042 randomly 2001). The researcher used published information to develop selected occupational therapists on October 1, 2004. both the e-mail notices (Schaefer & Dillman) and the design A follow-up letter or e-mail was sent to the therapists of the web-based survey (Dillman & Bowker; Dillman, three weeks later, and an incentive was available in the form Tortora, & Bowker, 1998; Klein). of a certificate of participation that could be printed from the A questionnaire was developed based on theoretical website and used for a professional portfolio. approaches and reasons for choosing specific assessments

Data analysis The regional representation of the respondents was com-

Descriptive statistics regarding frequencies and percentages pared to the membership in CAOT (n=5,090) and all occupa-were obtained using SPSS software (SPSS Inc., 2004). Open- tional therapists in the country (n=9,485). Some of theended questions with the names of the assessments were provinces had expected numbers of less than five practicinggrouped according to whether the assessment was standard- occupational therapists; therefore, the provinces were groupedised or non-standardised. The non-standardised assessments into regions to allow the use of a chi-square calculation. Thewere categorised according to similarities in the type of task following regions were used: British Columbia, Prairieperformed, such as being interviewed or participating in Provinces (Alberta, Saskatchewan, and Manitoba), Ontario,kitchen tasks. Subsequently, the assessments were categorised Quebec, and Atlantic Provinces and Territories (Newaccording to theoretical approach (i.e., bottom-up or top- Brunswick, Nova Scotia, Prince Edward Island,down). The first author assigned the assessments to each Newfoundland, Nunavut, Yukon Territories, and Northwestgroup based on the literature review or by checking the test Territories). The groupings were based solely on numbers ofmanuals regarding the assessment description, purpose, and respondents rather than any perceived similarity in culture,theoretical approach. The categories were checked by the sec- working conditions, or geographic proximity. There was a sig-ond author. If the assessment was not given a standardised nificant difference between distributions in region of residencename, the assessment was assumed to be non-standardised; when comparing the respondents to the membership in CAOTfor example, “word list” as a possible response was catego- (x2=46.19, df =4, p<.001), and to all occupational therapists inrized as a non-standardised assessment because it was from a the country (x2=63.30, df=4, p<.001). Compared to the CAOTlist generated by the therapist, and, therefore, could not be membership, there was also a proportionally higher represen-identified as a particular standardised assessment. tation of respondents from the Prairie Provinces. Chi-square analyses were used to determine how to In Part A of the questionnaire, the respondents werecompare the composition of the sample to practicing asked about the theoretical approaches they used for cogni-Canadian occupational therapists (n=9,485), and to the tive assessment. The combined approach was the mostmembership of the CAOT (n=5,090) (CAOT, 2001). Chisquare analyses were also used to examine the variability in TABLE 1the use of each theoretical approach to cognitive assessment Demographic description of respondentsacross geographic regions. Post-hoc analysis using Yates Characteristic Frequency among respondentsCorrelation Coefficient was used to determine specific differ- Number (n) Percent (%)ences in the use of theoretical approach by geographic region. Gender (n= 214) Results Male 11 5.1There were 1042 surveys sent by e-mail and post, of which 35 Female 203 94.9were returned undeliverable (34 by e-mail, 1 by post). From Age Group (n=219)the 1008 deliverable surveys, 251 were returned (24.9%), and 65 and over 1 0.5247 of them were deemed valid, indicating a valid response 55-64 10 4.5rate of 24.5%. 45-54 47 21.4 Among the 247 valid questionnaires, 167 (67.6%) were 35-44 73 33.6 25-34 82 37.3completed through the web-based survey, 43 (17.4%) were 24 and under 6 2.7completed electronically and returned via e-mail, and 37(15.0%) were paper versions returned to the researcher by Place of Residence (n=216)post. The respondents were asked to indicate how they British Columbia 21 8.5received the invitation to participate in the study. There were Atlantic Provinces & Territories 11 5.1 Ontario 76 30.8140 responses from direct e-mail requests (17.3% e-mail Quebec 30 12.1response rate), and 45 responses from direct postal requests Prairie Provinces 78 36.1(22.3% postal response rate). The number of respondentsindicating that they had received requests from indirect Primary Work Setting (n=216)sources such as advertising, forwarded e-mails, and by word General hospital 78 36.7 Client's home 54 24.8of mouth was 36 (14.6% of respondents). Rehabilitation centre 34 15.6 The demographic characteristics of the respondents are Community clinic 7 3.2shown in Table 1. There was no significant difference Private health business 4 1.8between the observed and expected gender distribution (x2= Mental health centre 8 3.7.93, df=1, p= .335) or age distribution (x2= 1.93, df=5, p= Post secondary 1 0.5 Chronic care/LTC 30 13.8.858) compared to membership statistics for CAOT.

frequently reported, followed by the top-down and then bot- combined approach. tom-up approaches (see Table 2). A chi-square analysis of the In Part B of the questionnaire, respondents were asked to reported frequency of each approach according to region of list up to five assessments (either standardised or non-stan- residence showed no significant differences in the distribu- dardised), which they used to assess cognition with older tions of the bottom-up approach, top-down approach, or adults. A total of 65 standardised and 9 non-standardised

assessments were reported, of which 20 (30.7%) had not been (97.8%) were standardised assessments. The majority ofpreviously reported in the literature related to occupational responses in the bottom-up group (99%, n=643) listed atherapy practice (Douglas & Liu, 2005). A reference list for standardised assessment. For the top-down group, a total ofthe assessments can be provided on request. 29 assessments were found (see Table 5). The majority of Respondents were asked to indicate the frequency of use responses in the top-down group (80.6%, n=294) listed aof each assessment, and a majority of the responses (n=372, non-standardised assessment.65.5%) indicated the assessment was used either 2 to 4 times The respondents were asked to indicate any or all ofper week or 1 to 5 times per month. The 15 most frequently three purposes that applied to each assessment. The resultsreported assessments are shown in Table 3 and listed accord- for the assessments grouped by theoretical approach areing to the respondents' regions of residence. Each of the shown in Table 6. The most frequently indicated purpose wasremaining 74 assessments was reported by less than 5% marked with an asterisk for each group. Bottom-up assess-(n=12) of respondents. The most frequently used standard- ments were more frequently reported to be used to "identifyised assessments (Mini Mental Status Exam and Cognitive deficits", while top-down assessments were more frequentlyCompetency Test) and non-standardised assessments reported to be used to predict.(General Activities of Daily Living, Kitchen task, and Clinical Ten possible reasons for choice of an assessment wereobservation) were used across the country, but others generated from the literature review. In the questionnaire, the(Cognitive Assessment Scale of the Elderly/Pecpa, Executive respondents were asked to rate the perceived importance ofInterview, and Rivermead Behavioral Memory Test) were each reason for each assessment they listed. Using a 5 pointpreferred by occupational therapists in certain regions. scale, from 1 reflecting "not important" to 5 reflecting "very The following tables list the names of assessments iden- important", the three reasons most frequently ranked bytified in use by respondents and the groups to which they respondents as important or very important were tabulatedwere allocated. A total of 46 assessments in the bottom-up for each assessment, as was the one reason most frequentlyapproach group were reported (see Table 4), of which 45 ranked not important.

For each of the 10 possible reasons, the number of chosen, except in the cases of the Mini Mental Status Exam assessments ranked important or very important was then and Cognitive Competency Test. Respondents for the Mini summed. Likewise, the number of assessments for which the Mental Status Exam used this option most frequently (n=21, reason was ranked not important was also calculated. Finally, 13.2%); with the most often described reason being that the the reasons ranked important and very important, as well as Mini Mental Status Exam was requested by others, such as not important for the greatest number of assessments were the physician, the team, or the program (n=19, 11.9 %). For tabulated (see Table 7). the Cognitive Competency Test, the other reason most fre- For the bottom-up group, the three reasons ranked quently described was that the testing tasks were related to important or very important for the greatest number of daily function and/or appeared to have face validity (n=6, assessments were 1) It is easily administered in my work setting 4.7%). These reasons were not reported in sufficient numbers (e.g., resources, space, and setup), 2) It can be administered in for them to be designated as one of the three highest ranked a reasonable amount of time, and 3) It is available. The reason reasons. The number of respondents that ranked them as ranked not important for the greatest number of assessments important or very important was lower than for all other rea- was It fits with my theoretical approach. sons; therefore, these responses were not included in the For the top-down group, the three reasons ranked overall summary table. important or very important for the greatest number of assessments were 1) It gives me the type of information TABLE 7 required for the team, client or family, 2) I am familiar with it, Reasons for choosing theoretical approach groups and 3) It fits with my theoretical approach. The reason ranked not important for the greatest number of assessments was It Reasons for choice Assessment group is used by my colleagues. of assessment Bottom-up Top-down The response other was also provided, with a blank for Available ✔ the respondents to specify the reason. This option was rarely Used by colleagues X ✔ Reported valid/reliable TABLE 6 Easily interpreted ✔ Purpose for using theoretical approach groups Type of info needed ✔ Administration time ✔ Assessment group Purpose (columns not mutually exclusive) Easy in setting ✔ Identify deficits Predict Measure change Familiarity Bottom-up 570* 316 242 Learning time Top-down 195 208* 88 Fits theoretical approach X

*purpose reported by the most respondents per assessment group ✔ : 3 reasons rated "important" or "very important" for the greatest number of Note: percentages could not be calculated because respondents could identify assessments more than one assessment within each group X: reason rated "not important" for the greatest number of assessment

Discussion ments when generating their own list. Because the respon-The purpose of the study was to delineate the assessments in dents were assured anonymity, it is expected that this desir-current use by occupational therapists and their pattern of ability bias was minimized. The discrepancy in reporting mayuse. In Part A of the questionnaire, the two most frequently have been due to a tendency to recall more standardised thanused theoretical approaches were the combined approach non-standardised assessments when asked to report aboutand top-down approach, respectively. In Part B, the numer- formal assessment procedures. Alternatively, it may have beenous listed assessments were used routinely with differences in more difficult for therapists to name or describe a non-stan-purposes and reasons for use noted between the bottom-up dardised task (e.g., kitchen task such as making coffee), thanand top-down groups. The findings in Part A were compared naming a standardised test.with the findings in Part B. The reported cognitive assessments were organised into The combined approach was the most popular and standardised and non-standardised groups. Subsequently,included both direct observation and an interview with the they were also organised according to theoretical approachclient, the family, or both. This approach was recommended (i.e., bottom-up and top-down). It was found that theas best practice in a review of validity of cognitive assess- responses regarding assessment purpose and reasons forments (Wells, Seabrook, Stolee, Borrie, & Knoefel, 2003) and choice had greatest similarity amongst assessments using thein a study demonstrating increased validity when using inter- same theoretical approach; therefore, they will be discussedviews in combination with bottom-up cognitive assessments according to theoretical approach.(MacKinnon & Mulligan, 1998). When examining the specific assessments reported, it is Bottom-up assessmentsnoted that the more frequently reported tools were used The bottom-up approach involves assessment of impair-across regions; however, a number of tools were used region- ments in cognitive function rather than assessment of abili-ally. The large list of assessments indicates that there is a wide ties to perform activities of daily living. In this study,range of practice for use of cognitive measures with older bottom-up assessments were reported to be used to identifyadults. The regional use of some assessments may result from deficits, which was the primary purpose for which thesethe influence of a local advocate for the assessment, univer- assessments were designed. The most popular of these assess-sity curricula, or local networks of clinicians. In contrast, ments were screening tools, for which sensitivity and speci-there was no significant difference found in the use of theo- ficity for identification of dementia has been studied in largeretical approaches between geographic regions of the coun- sample sizes (Lorentz, Scanlan, & Borson, 2002; Wells et al.try. This result showed that the theoretical approach to 2003).cognitive assessment with older adults is similar across Availability, administration time, and ease of adminis-geographic regions of the country. It also suggests that tration were the most highly ranked reasons for choosingrespondents were seeking similar types of assessments in bottom-up assessments. These assessments generally can betheir practice and would benefit from the use of assessments administered at the bedside or in a quiet room with a table,that employed similar approaches. and were designed with ease of administration as a main con- In Part B of the questionnaire, more respondents listed sideration. These findings suggest that occupational thera-standardised compared to non-standardised assessments. pists value assessments that are easily and quicklyThis result may indicate that therapists used a greater variety administered and readily available. They are seen as impor-of standardised assessments, despite using non-standardised tant factors in the clinical utility of cognitive assessments inassessments more frequently. However, respondents may this study, and must be taken into consideration whenhave under-reported the use of non-standardised assess- reviewing and developing cognitive assessments for occupa-ments in Part B. It was noted that 60.6% of respondents tional therapy.indicated using interviews when rating a list in Part A (theo- The reason, It was reported to have good reliability, valid-retical approaches), whereas in Part B, only 21.3% listed ity or responsiveness for its stated purpose, was ranked lowerinterviews. This discrepancy in reporting of interviews than anticipated. It must be noted that the respondents werebetween Parts A and B provided evidence of a non-standard- not asked to rank items in terms of clinical practice, but rea-ised test that was likely underreported in Part B. Many thera- sons for choice of a particular assessment. Thus, the lowerpists may have considered only standardised assessments ranking of this reason may reflect skepticism or uncertaintywhen asked to list the assessments they used, despite the fact about the assessments' psychometric properties rather than athat the questionnaire cued them to recall both standardised devaluing of these attributes in clinical practice as a whole.and non-standardised assessments. Given the current Despite their widespread use and popularity, respon-emphasis on evidence-based practice, many therapists may dents indicated that the bottom-up assessments did not fithave perceived that they should be using standardised assess- with the occupational therapists' theoretical approach. Thements and, therefore, discounted non-standardised assess- definition of theoretical approach was not specified in the

questionnaire; however, the occupational therapy approach Mulley (1999), and they concluded that the evidence lacked involves an emphasis on how impairments in performance rigor to support their "effectiveness." components, such as cognition, affect daily function in self- The results of the current survey demonstrate that occu- care, productivity, and leisure (CAOT, 1997). The therapists' pational therapists are using top-down cognitive assessments perceived lack of fit between these assessments and occupa- to predict safety, yet the literature demonstrates a gap in the tional therapy's theoretical approach is notable in that it indi- data upon which to base these predictions. Therapists are cates a gap in the ability of the most common cognitive required to rely on clinical reasoning when using non- assessments to measure function. This disparity will be standardised assessments to predict safety, and this has been discussed further in the discussion on top-down assessments. demonstrated to vary significantly, depending on the occu- An exception to this pattern was noted with the pational therapists' experience (Reich, Eastwood, Tilling, & Cognitive Competency Test and the Independent Living Hopper, 1998). Scales. These assessments were in the bottom-up group; how- For both bottom-up and top-down assessments, the ever, they were most often reported to be used for the purpose of measurement of change was the least reported. purpose of prediction and chosen for their ease of interpre- This may be an indication that therapists were relying on tation and the type of information they provided. These other outcome measures besides cognitive assessments to assessments use more functional tasks to evaluate cognitive measure change. Therapists may not expect significant capacities, for example, the memory task requires the recall of change in cognitive scores after occupational therapy inter- a grocery list rather than the recall of three words. The pop- vention, because the focus of intervention may be on com- ularity of the Cognitive Competency Test may be attributable pensation for cognitive deficits. Instead, data from the client's to the face validity of its tasks, despite its poorer psychomet- performance of treatment activities may be used to measure ric properties compared to other assessments in this category change, as progress towards these goals is a primary outcome (Douglas & Liu, 2005). measure in clinical practice. Alternatively, it may indicate that therapists are not measuring change as often as identifying Top-down assessments deficits or prediction. The most frequently reported top-down assessments in this The occupational therapists' reasons for choosing top- group were non-standardised assessments, such as ADL or down assessments also differed from bottom-up assessments. kitchen tasks. Several standardised assessments exist in this Top-down assessments were chosen because they gave category including the Kitchen Task Assessment or the needed information and fit with the therapists' theoretical Assessment of Motor and Process Skills. However, when the approach rather than because they were easy to administer. It occupational therapists assessed with a top-down approach, was unanticipated that therapists would rank fit with the the- the majority of responses (80.6%) indicated that they used oretical approach as important in their choice of cognitive non-standardised tasks. assessments. The assessments that fit the occupational thera- The top-down assessments were used for multiple pur- pists' theoretical approach were largely non-standardised, poses including identifying deficits (n=195) and predicting and were used for prediction of safety and the need for com- safety or clients' need for services (n=208). The characteristic pensatory intervention. The occupational therapists in this that these assessments had multiple purposes from the bot- study indicated that assessments that measure outcomes at tom-up assessments, which were used most often for a single the functional level provide valuable information, and can be purpose (identifying deficits). used to predict safety and function for older adults. However, Milberg (1996) described the need for efficient cognitive in the survey, they also noted barriers to use these assess- assessment tools in light of the projected increase in the ments including the availability and training required. elderly population in North America. Efficient assessment Assessments such as the Assessment of Motor and Process tools are those that would provide information on functional Skills require training time and cost that make these much abilities and cognitive capacities, rather than just one or the less accessible to therapists and, therefore, limit their use. other. The respondents identified top-down assessments to The importance of measuring outcomes that reflect daily serve a greater range of purposes than bottom-up assess- living function has been noted in pediatric occupational ments of cognition in older adults. therapy (Burtner et al. 2002; Watling et al., 1999). In a survey, Because the majority of therapists reported the use of occupational therapists in hand therapy have also noted a non-standardised assessments in this group, the results show preference for non-standardised over standardised assess- that when the therapists were required to predict safety, most ments (Blenkiron, 2005). The hand therapists noted reasons used non-standardised assessments. Yet, the predictive valid- for use of non-standardised assessments that included famil- ity of non-standardised assessments with older adults has iarity and availability, but also stated the non-standardised been called into question. Studies of non-standardised home assessments "followed a model of practice" (p. 153), and assessments were systematically reviewed by Patterson and "[took] into account my role… i.e., assessing ADL [activities

of daily living] function, person's social situation …" (p.153). ity. With increased emphasis on the measurement of out-Although Blenkiron concluded that therapists lacked knowl- comes, occupational therapists may use standardised assess-edge about standardised assessments, respondents in the ments more frequently, and begin to incorporate more ofstudy suggested that they were not using standardised assess- them into the assessment of activity and participation.ments because those available in hand therapy did not fit The similar use of theoretical approaches across regionswith the theoretical model of practice, including assessment indicates that, despite regional differences in use of specificof daily function. The respondents, therefore, noted that the assessments, all regions may benefit from assessments thatstandardised assessments were not clinically useful for all employ a similar approach. Future research is warranted topurposes. Researchers are advised to promote clinically use- determine if similar assessments can be used across regionsful assessment instruments with evidence to support their of the country.use for a given purpose. Assessments that measure outcomes In this study, occupational therapists stated that theyrelevant to daily function have clinical utility because they used bottom-up assessments to identify deficits; importantcan be used for multiple purposes, and they fit with the occu- reasons for their choice included that the assessments werepational therapy model of practice. easy and took a reasonable time to administer. They also noted that the bottom-up assessments did not fit with their Study limitations theoretical approach, whereas the top-down assessments notThe sample was representative of occupational therapists only fit with their theoretical approach, but could be used forworking in Canada in terms of gender and age distribution. both identification of deficits and prediction of safety or needThe generalizability of the results is limited by the sample size for services. Furthermore, the therapists reported greater useand the greater number of respondents from the region of of the top-down approach to assessment over the bottom-upthe country from which the survey originated. approach. The respondents identified top-down assessments The study used a self-report questionnaire, which has as serving a greater range of purposes than bottom-up assess-inherent limitations. Although the respondents were ensured ments of cognition in older adults.anonymity and were requested to list assessments from mem- When researchers and clinicians develop assessmentory rather than from a list, it was possible that they underre- tools, the reasons influencing therapists' choice of assessmentported non-standardised assessments in Part B of the tools should be considered. The data from this study can bequestionnaire. This may have been due to a desirability bias used to identify the types of tools that occupational therapiststowards the use of standardised assessments which was not find clinically useful. They can also be used by clinicians toovercome by the cues provided in the questionnaire. The weigh the expected advantages and disadvantages of certaintherapists' perceptions of what entailed assessment may also measures. Research into the benefits of using outcome mea-have reduced the number of non-standardised assessments sures to enhance client care would improve client-centredreported. practice in occupational therapy. Data regarding the predic- The study also did not determine if the reported stan- tive properties of functional assessments for use in occupa-dardised assessments were administered in a standardised tional therapy would increase the value of these assessmentsway. The therapists' knowledge of the psychometric data and improve care for clients as well. Further research into the(reliability, validity studies) was not challenged or assessed by therapists' perceived and actual knowledge of reliability andthe questionnaire. Instead, the questionnaire sought infor- validity would also be valuable to determine if the lowermation about whether the reliability and validity of an importance rankings reflected a lack of knowledge or confi-instrument were important reasons for its use. dence with these criteria. This survey of current practice into cognitive assessment Implications for practice with older adults demonstrated that the majority of thera-The study describes a wide range of cognitive assessments pists who use top-down assessments were using non-stan-used with older adults, many not previously documented in dardised assessments. This result was not unique to this areathe occupational therapy literature. The results can provide of occupational therapy practice. The top-down assessmentsresearchers and clinicians with the most common assess- were noted to fit with the theoretical approach, which forments currently used in occupational therapy and also occupational therapists emphasizes client-centredness andinform occupational therapy educators in preparing entry- the importance of meaningful activity. Development andlevel occupational therapy students for clinical practice. The promotion of top-down assessments that are standardisedlist of currently used assessments can form the basis for a for use with older adults would provide efficient and clini-critical review of the psychometric properties of assessments. cally useful measures for therapists. Moreover, their use willThe dissemination of reviews of psychometric properties for be necessary to improve evidence-based practice in occupa-particular assessments may increase the use of assessments tional therapy.with the best evidence to support their reliability and valid-

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Fine Motor Skills for Children with Down Syndrome: describes what can facilitate development and recommends manyA Guide for Parents and Professionals, 2nd edition activities that are broken down into steps emphasizing activities of(2006) daily living and play.Maryanne Bruin The section on goal setting for the child’s EducationalWoodbine House via Monarch Books of Canada Program Plan (EPP) gives examples of clear, measurable, achiev-5000 Dufferin Street able goals. The “Developmental Chart for Preprinting Skills” isDownsview, Ontario, M3H 5T5 excellent in explaining the progression to printing readiness. The241 pages; $19.95 US chapter on “Sensory Processing” is interesting and analogy is skill-ISBN: 978-1-890627-67-6 fully used to explain modulation. Several charts cover examples ofMaryanne Bruin is an occupational therapist who is also the par- sensory processing difficulties and strategies. However I feel thatent of a child with Down syndrome. The tone of her book is one the role of the occupational therapist in identifying areas of dys-of theory, understanding and compassion as only one who experi- function in sensory processing and developing a program isences a child with Down syndrome on a daily basis could express. underplayed.It is well organized and easy to read. This resource is valuable for parents, teachers and therapists. She explains fine motor development in terms of building It will help every team member develop a better understanding ofblocks emphasizing the foundation blocks required to achieve fine motor skill development and therefore facilitate collaborationcontrol and dexterity. This analogy works well in explaining the when working with a child with Down syndrome. It offers ther-developmental process. She describes motor milestones emphasiz- apists insight into the experiences of parents and ways to help par-ing the progression of development and the importance of accept- ents understand the process.ing and understanding that each child progresses individually. She Jane Henry